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Home My WebLink AboutBLDP-26-746 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =`41_- CITY/TOWN "CV' MD v MA DATE37444224,_ PERMIT#.71.1 —Zb 7 • JOBSITE ADDRESS 3 C Lk, ///1 /C J94 OWNERS NAME/ -f erA 4 [-Y OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL I. EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:9::J PLANS SUBMITTED:YES❑ NO,. FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL RECEIVE D WASHING MACHINE CONNECTION WATER HEATER ALL TYPES / Po4 2O16 WATER PIPING J OTHER e c W, li _ B etc INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 04, OTHER TYPE OF INDEMNITY❑ BOND❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application I be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code/ and Chapter 142 of the General Laws. n PLUMBER'S NAME VAJ dike � 0"L n (7 LICENSE##9�j t SIGNATURE MP❑ JP❑ CORPORATION❑# I J��/D Q PARTNERSHIP❑# LLC❑J#,p COMPAN NAME li 't cJ(Y O I" 17— 4- ADDRESS7 37 rre:4,16//r/► Ate CITY / 4/1✓1 I, 3 STATE/ Y/ ZIP(/71lJ/ TEL 77 570 7/rZ FAX CELL EMAILSI, er•iv%c_e itcfLoap ?t 4/c• CD'� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations MEM_SW r 111. Lafayette City Center EILAT 2. 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): /� G t i p t"j - AA�/'3 r/4 Address: wir , ( ""��"��"'�� Aeie City/State/Zip: mA 4 / 5 26G'/ Phone #: 77 F(to JAI Z Are you an employer? Ch ck the appropriate box: Type of project (required): 4. ❑ I am a general contractor and I 1.El I am a employer with employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction listed on the attached sheet. 7. Remodeling❑ 2.LI am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p y t 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 1 1.❑ Plumbing repairs or additions 3.El I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided ab ve is true and correct. ASignature: J C _ Date: { 3 O Z Phone#: ^] . Z TA) J 7i Z Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority(check one): 1❑Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: